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JAMA Ophthalmology Clinical Challenge
June 2018

Visual Disturbance in a Middle-aged Woman With Non–Small Cell Lung Cancer

Author Affiliations
  • 1Currently a medical student at University of Rochester School of Medicine, Rochester, New York
  • 2Flaum Eye Institute, University of Rochester Medical Center, Rochester, New York
JAMA Ophthalmol. 2018;136(6):702-703. doi:10.1001/jamaophthalmol.2017.5776

A middle-aged woman with a history of stage IV anaplastic lymphoma kinase (ALK)–positive non–small cell lung cancer (NSCLC) treated with crizotinib, an oral small-molecule tyrosine kinase inhibitor of ALK and other oncogenic kinases, presented with several months of peripheral visual field loss in her left eye. Four years earlier, she was diagnosed with stage IIIA NSCLC, which was managed with pneumonectomy, adjuvant chemotherapy, and radiotherapy. Seven months later, she underwent localized radiotherapy for a metastatic iliac lesion. Further testing revealed tumor positivity for the EML4-ALK gene (OMIM 607442) rearrangement, and the patient started crizotinib therapy. One month before presentation, she had an eye examination at another office and was prescribed new glasses, which did not improve her visual field deficit. One week before presentation, surveillance magnetic resonance imaging (MRI) showed a new 4-mm metastatic lesion in her right temporal lobe. On presentation, the patient’s visual acuity was 20/25 OD and 20/20 −2 OS. Tonometry showed pressures of 16 mm Hg OD and 14 mm Hg OS. Pupillary examination showed a trace relative afferent pupillary defect in the left eye. The remainder of the anterior segment examination findings were within normal limits. Goldmann visual field testing revealed an inferior defect in the left eye (Figure 1).